Recommendations to Improve Neonatal Circumcision Training.

BACKGROUND: Although multiple specialties perform neonatal circumcision (NC), overall NC proceduralist availability is limited. The approach to training new practitioners varies. This study aims to describe NC training experiences, current practices, and make suggestions for future improvements. METHODS: Perinatal physicians across 11 hospitals in a large Midwestern United States city who perform NC or who conduct newborn examinations and provide circumcision counseling were recruited for semistructured interviews about NC care. Interviews were transcribed; training-related comments underwent inductive and deductive qualitative coding. Themes related to circumcision training and recommendations for improving the experience of future circumcision learners were summarized. RESULTS: Twenty-three physicians (10 family medicine, 8 pediatrics, and 5 obstetrics; 78% currently perform circumcision) participated. All participants conducted newborn examinations and provided circumcision counseling, but only 21/23 were trained to perform circumcision. Several themes related to training emerged: (1) personal training experience, (2) training others to perform circumcision, and (3) current training needs and barriers. Most reported learning in residency by a "see one, do one, teach one" approach with minimal formal didactic or structured training. Compared with their personal experience, participants noted a shift toward more direct supervision and preprocedure preparation for current trainees. However, most reported that circumcision learning continues to be "hands-on." Participants desired a more structured approach for future trainees. CONCLUSIONS: Perinatal physicians noted a shift in the current NC training to a more hands-on approach than they experienced personally. Development of a structured NC curriculum was recommended to improve training.

Growth in Newborn Circumcisions Performed by Pediatric Urologists and Advanced Practice Providers Between 2010 and 2021 in the United States.

OBJECTIVE: To characterize changes in the proportion of newborn circumcisions performed by pediatric urologists and advanced practiced providers (APPs) in the United States over the last decade. METHODS: The Merative MarketScan Commercial Database was queried for newborn circumcision private health insurance claims (Common Procedural Terminology 54150) between 2010 and 2021. Setting (inpatient/outpatient), US Census Bureau region, clinician specialty, and patient age (days) were determined for the full study time period, and by study year. Simple linear regression assessed growth in proportion of newborn circumcisions performed by pediatric urologists and APPs (nurse practitioner/physician assistant/midwife), over time. RESULTS: In total, 1,006,748 newborn circumcisions (59% inpatient) were identified; while most were performed by obstetricians (45%) or pediatricians (33%); APPs performed 0.9%, and pediatric urologists performed 0.7%. From 2010-2021, the proportion of newborn circumcisions performed by pediatric urologists increased from 0.3% to 2.0% and by APPs in from 0.5% to 2.9% (P < .001 for both). Growth for both pediatric urologists and APPs occurred APPs predominantly from 2016 to 2021. Trends in proportion of newborn circumcision performed by pediatricians was stable [31.5% (2010) and 32.5% (2021)], but decreased for obstetricians [48.8% (2014) and 38.1% (2021)]. CONCLUSION: The proportion of newborn circumcisions performed by pediatric urologists and APPs increased more than 6-fold between 2010 and 2021, though both specialties still perform a minority of newborn circumcisions. These data provide important baseline information for newborn circumcision workforce planning, including evaluating collaborative care models where pediatric urologists train APPs to perform circumcision.

Retrograde incision from orifice (RIO) technique for endoscopic incision of ureterocele: 15 years of outcomes.

INTRODUCTION: Management of obstructing ureterocele often includes endoscopic transurethral incision (TUI) that can be challenging secondary to uncertainty in anatomic landmarks with risk of serious complications. To this end, we innovated a technique using predictable landmarks that begins endoscopic incision at the ureterocele orifice and extends retrograde proximal to the bladder neck (Figure). OBJECTIVE: With over 15 years of experience in performing this retrograde incision from orifice (RIO) technique, we aimed to examine post-operative outcomes and risk of surgical failure after RIO compared to traditional TUI techniques for ureteroceles. We hypothesized that clinical outcomes after RIO would be superior to traditional endoscopic approaches to decompression of obstructing ureterocele in infants. STUDY DESIGN: A retrospective study of patients ≤12 months old who underwent TUI ureterocele at our institution between 2007 and -2021 was conducted. Pre-, intra- and post-operative characteristics were compared between patients who underwent RIO vs non-RIO TUI. Primary outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome was a composite failure measure of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional hazard models were fitted to compare the time-to-event risk of primary and secondary outcomes between groups. RESULTS: Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Median follow-up from TUI was 33 months. RIO had a shorter median operative duration (27 vs 35 min, p = 0.021). Primary and secondary outcomes were similar between groups (fUTI: 29% RIO vs 19% non-RIO, p = 0.27; composite failure 54% RIO vs 69% non-RIO, p = 0.15). In multivariable Cox proportional hazard models, there was no significant difference in risk of fUTI (RIO aHR 0.98, 95% CI 0.38-2.54, p = 0.97) or composite failure (RIO aHR 0.80, 95% CI 0.45-1.44, p = 0.46) between TUI techniques. DISCUSSION: RIO technique for TUI ureterocele is attractive in that it uses predictable anatomic landmarks making it simple to perform. In analyzing this 15-year institutional experience of TUI ureterocele, RIO showed similar success to non-RIO endoscopic incisions. This study is a retrospective, non-randomized, single-institutional study over 15 years and is therefore subject to change in surgeon practice over time and variable practices between providers. CONCLUSIONS: Given comparable success and durability over time to other TUI ureterocele techniques, and with the advantage of operator ease using consistent anatomic landmarks, RIO is a worthy option for endoscopic ureterocele decompression.

Streamlining surgical trays for common pediatric urology Procedures: A quality improvement initiative.

INTRODUCTION: Procedures involving the external genitalia are the most common pediatric urologic operations. Our group identified excess instrumentation for these cases to be a potential cause of operating room (OR) inefficiency at our large, freestanding pediatric hospital. This quality improvement (QI) initiative aimed to streamline surgical instrumentation for the most-performed pediatric urologic procedures at our hospital. MATERIAL AND METHODS: Six Sigma DMAIC methodology (Define, Measure, Analyze, Improve, Control) guided this multidisciplinary, iterative QI effort. A stakeholder team utilized data review, direct observations, and multiple in-person discussions to create a new "Groin-Penis Tray" (GPT) to replace a larger tray for the 90 most common pediatric urologic procedures. Suture preference cards and expectations about which sutures would be opened for each case were updated. The primary outcome was estimated yearly cost-avoidance due to reduced sterile processing. Additional outcomes included: instruments opened/case, % cases with complete trays, Mayo stand set-up time, and % cases with unused sutures. Balancing measures included: total median OR time and tray weights. Baseline and post-implementation measures were characterized and compared. RESULTS: A QI professional, 10 pediatric urologists, 2 pediatric urology fellows, and multiple OR and sterile processing staff members participated. The Summary Figure compares baseline and post-implementation measurements. The number of instruments opened/case decreased from 146 to 65. Annual sterile reprocessing costs decreased by >$51,000. Median Mayo stand set-up time decreased from 7.3 to 3.5 min (p < 0.001). The number of cases with complete trays increased from 7/20 (35%) to 11/20 (55%, p = 0.34). The new GPT is 2.7 kg lighter than the prior tray. Median OR time remained stable (baseline: 91 min; post-implementation: 102 min, p = 0.44). The number of cases with suture waste decreased from 78% to 0% immediately post-implementation but increased to 40% one year later. DISCUSSION: This systematic, iterative QI process spanned the course of ∼2 years, including planning, building, and updating new trays, then assessing longer-term success via the control phase. The new GPT is used for most pediatric urologic procedures at our hospital, and benefits include sterile reprocessing cost savings and ergonomics. Our team gained valuable experience related to assessing QI project scope, determining key stakeholders and roles, and strategies for sustainability that we will apply to future initiatives. CONCLUSIONS: Streamlining surgical trays for common pediatric urologic procedures at a large freestanding children's hospital using established QI methodology reduced OR cost by >$51,000/year and Mayo stand set-up times without compromising balancing measures.

Randomized trial of prophylactic antibiotics vs. placebo after midshaft-to-distal hypospadias repair: the PROPHY Study.

BACKGROUND: Use of prophylactic antibiotics after stented hypospadias repair is very common, but most research has not identified any clinical benefits of this practice. Only one study has found that postoperative prophylaxis reduces symptomatic urinary tract infections (UTIs). Data from the same trial suggested that prophylaxis may also reduce urethroplasty complications. No studies on this subject have been placebo-controlled. OBJECTIVE: We performed a randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative prophylactic antibiotics on the incidence of infection or urethroplasty complications after stented repair of midshaft-to-distal hypospadias. STUDY DESIGN: Boys were eligible for this multicenter trial if they had a primary, single-stage repair of mid-to-distal hypospadias with placement of an open-drainage urethral stent for an intended duration of 5-10 days. Participants were randomized in a double-blind fashion to receive oral trimethoprim-sulfamethoxazole or placebo twice daily for 10 days postoperatively. The primary outcome was a composite of symptomatic UTI, surgical site infection (SSI), and urethroplasty complications, including urethrocutaneous fistula, meatal stenosis, and dehiscence. Secondary outcomes included each component of the primary outcome as well as acute adverse drug reactions (ADRs) and C. difficile colitis. RESULTS: Infection or urethroplasty complications occurred in 10 of 45 boys (22%) assigned to receive antibiotic prophylaxis as compared with 5 of 48 (10%) who received placebo (relative risk [RR], 2.1; 95% confidence interval [CI], 0.8 to 5.8; p = 0.16). There were no significant differences between groups in symptomatic UTIs, SSIs, or any urethroplasty complications. Mild ADRs occurred in 3 of 45 boys (7%) assigned to antibiotics as compared with 5 of 48 (10%) given placebo (RR, 0.6; 95% CI, 0.2 to 2.5; p = 0.72). There were no moderate-to-severe ADRs, and no patients developed C. difficile colitis. CONCLUSIONS: In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. The study did not reach its desired sample size and was therefore underpowered to independently support a conclusion that prophylaxis is not beneficial. However, the result is consistent with most prior research on this subject. GOV IDENTIFIER: NCT02096159.

Development and Outcomes of a Streamlined Outpatient Newborn Circumcision Clinic.

INTRODUCTION: Abnormal penile anatomy is suspected in approximately 20% of newborns whose families desire circumcision, yet there is no clear method to refer such cases for anatomical assessment and circumcision under local anesthesia when safe. The aim of this study was to describe development, implementation and outcomes of a newborn circumcision clinic for boys where concern about anatomical circumcision suitability exists. METHODS: The workflow of a pediatric urology outpatient clinic was modified and a circumcision clinic implemented. Staff educational materials and electronic medical record referral templates were created. Circumcision suitability was assessed via checklist, and suitable patients circumcised on the same day. Clinical data were reviewed to evaluate initial implementation and patient outcomes. RESULTS: Of 833 boys evaluated from January 2014 to April 2018, 657 (79%) were suitable to circumcise, all of whom underwent a circumcision. Of those suitable 244 (37%) had normal anatomy. The remaining 413 (63%) had minor anatomical abnormalities, most commonly penoscrotal web (297/657, 45%) and penile raphe deviation (60/657, 9%). No short-term complications were noted. Most (595/657, 91%) returned for followup within 6 weeks after circumcision. Success was achieved in 593/595 boys (99.7%), and 2 boys (0.3%) required acquired buried penis repair. Of the 176 boys with anatomy unsuitable for clamp circumcision (buried penis, chordee or hypospadias), 144/176 (82%) elected for surgical reconstruction. CONCLUSIONS: Implementing a newborn circumcision clinic for boys with possible anatomical abnormalities is feasible. Most boys are circumcised safely and successfully without general anesthesia. Operative circumcision under general anesthesia is reserved for boys requiring surgical reconstruction for significant anatomical abnormalities.

Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair.

INTRODUCTION: The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The 'M' component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in 'meatal mismatch.' OBJECTIVE: To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development. STUDY DESIGN: We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with <6 months of follow-up. RESULTS: Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0-20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44-6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29-3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09-0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings. DISCUSSION: Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias. CONCLUSIONS: Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development.

Assessment of operative competency for thyroidectomy: Comparison of resident self-assessment vs attending surgeon assessment.

BACKGROUND: Self-awareness of skill, essential for progression as a surgeon, has direct bearing on postresidency practice; however, studies have supported that residents achieve self-perceived competence later than believed by program directors. This study compares residents' self-perception of operative competency to attending surgeon's evaluation using Computer Enhanced Visual Learning, a validated online hemithyroidectomy-specific assessment tool. METHODS: Eleven otolaryngology-Head and Neck Surgery (HNS) residents completed a preoperative module and postoperative survey, later reviewed by an attending surgeon. Eighty-three performances were assessed for inter-rater reliabilities of key surgical steps. RESULTS: Almost perfect agreement (Kappa = 0.81-1.00) was shown in 11 of 18 parameters. Substantial agreement (Kappa = 0.61-0.80) was demonstrated in the remaining seven parameters. CONCLUSIONS: Otolaryngology-HNS trainees have high self-awareness of their performance at each step in a hemithyroidectomy. Standardized assessment tools can allow for documentation of procedural performance and serve as guides for improvement. This is the only study to examine otolaryngology-HNS trainees' self-perceived skill compared to an attending surgeon's assessment for hemithyroidectomy.

Caregiver Reported Reasons for Delay of Neonatal Circumcision.

OBJECTIVES: To determine caregiver-reported reasons for delay of desired neonatal circumcision. METHODS: Caregivers requesting elective outpatient circumcision at two urban tertiary care hospitals were surveyed from 1/2017 to 12/2018. Boys >3 years and those with abnormal penile anatomy were excluded. Patient/parent demographics, insurance status, comorbidities, birth history, family history, reasons circumcision was desired, and reasons for circumcision delay were obtained. RESULTS: Surveys were completed by 206/229 caregivers (90% response rate). Respondents were primarily mothers (74%) who identified as African-American (62%). Eligible boys presented at a median 7.5 months [0.3-35.6] and were predominantly African-American (63%), publicly-insured at birth (83%), and publicly-insured at present (86%). 80% were full-term. 83% had no comorbidities. Most caregivers (84%) requested inpatient circumcision, primarily for penile cleanliness (75%) and infection prevention (72%). Common reasons for delay included neonatal circumcision not being performed by the birth physician/hospital (26%) and prematurity (16%). Publicly-insured boys were more likely to encounter delays related birth physician/hospital not performing circumcisions (P = .02). Non-Caucasian/mixed race boys were less likely to be eligible for circumcision without general anesthesia (P = .004). In 108 cases (52%), circumcision was requested for full-term boys without comorbidities. Of these, 72 (35% of the cohort) now require general anesthesia to undergo circumcision. CONCLUSION: Among 206 boys experiencing circumcision delay, most were full-term, African-American, and publicly-insured. Common reasons for delay included neonatal circumcision not being performed by the birth hospital/physician and prematurity. General anesthesia could have been avoided in >35% of boys if circumcision was performed at birth.

A qualitative study of parental preferences for postcircumcision care education.

INTRODUCTIONR/BACKGROUND: Although uncommon, complications associated with newborn male circumcision may require costly and emotionally upsetting surgical revisions. Improvements in parental education regarding postcircumcision care may reduce preventable complications; however, little is known about parents' preferences for education of this type. OBJECTIVE: The authors sought to describe parents' preferences regarding the content and delivery of education on postcircumcision care as a first step toward improving parental education and ultimately reducing the need for surgical revisions. STUDY DESIGN: The authors conducted a qualitative, descriptive study, collecting data from 14 parents during two separate focus group discussions. The authors applied thematic analysis techniques to analyze the transcribed content of both groups. RESULTS: Parents indicated that postcircumcision care instructions should be detailed and include clear images and/or an actual demonstration of care processes. Despite being aware of the low likelihood of complications, parents expressed a preference for providers who took education seriously rather than those approaching it with a 'cavalier attitude.' There was widespread support for delivering education at a time that met each family's unique circumstances and needs. DISCUSSION: Consistent with prior research, parents in this study identified gaps in understanding postprocedure care instructions. However, this study adds to the literature in highlighting the specific concerns and preferences of parents with regard to the content and delivery of postcircumcision care education. Based on these findings, the authors conclude that healthcare teams should ensure that parents have access to detailed instructions for postcircumcision care. Education of parents should occur at times when they are able to pay attention and should be supplemented with materials that they can easily access from home. Pediatric urologists can play a leading role in the development and dissemination of high-quality, family-centered educational materials to both parents and providers in other specialty areas that perform high volumes of newborn circumcision. Future research would benefit from larger, more diverse samples. In addition, future studies investigating the effect of parental education on potentially avoidable complications are needed to maximize clinical impact. CONCLUSION: Parents readily provided detailed input into what they perceived as much-needed improvements in postcircumcision care education. Future research is needed to determine what effect, if any, such changes would have on the incidence of preventable complications, particularly those requiring surgical intervention.

The Correlation between Serial Ultrasound and Diuretic Renography in Children with Severe Unilateral Hydronephrosis.

PURPOSE: While serial renal ultrasound is often used as an alternative to functional renal imaging in children followed for hydronephrosis, it is unclear whether a lack of hydronephrosis progression safeguards against loss of renal function. In this study we characterize the association between findings on serial renal ultrasound and diuretic renography in children with severe unilateral hydronephrosis. MATERIALS AND METHODS: We retrospectively reviewed imaging among patients younger than 18 years old with a history of severe unilateral hydronephrosis, 2 renal ultrasounds and 2 diuretic renograms. Each pair of renal ultrasounds was interpreted by an independent blinded diagnostic radiologist and compared to a contemporaneous diuretic renogram. Change in hydronephrosis was considered as 1) a change in hydronephrosis grade or 2) any change by radiologist interpretation. A 5% or greater change in split differential function was considered significant. Chi-square and Spearman correlation analyses were performed. RESULTS: A total of 85 children were evaluated. Increased hydronephrosis was noted in 11.8% of children by grade and 32.9% by radiologist interpretation. Split differential renal function worsened by 5% or more in 17.6% of children. Overall, 13.3% of children with stable or decreased hydronephrosis demonstrated worsening split differential function at an average of 11.8 months. When renal ultrasound and diuretic renograms were directly compared, the Spearman correlation was poor (r = 0.24, 95% CI 0.03 to 0.43). CONCLUSIONS: The overall correlation between imaging modalities was poor, and 13.3% of children with stable or decreased hydronephrosis had worsening of split differential renal function. These findings are important to consider when counseling nonoperatively managed children followed without diuretic renography.

E-learning teaches attendings "how to" objectively assess pediatric urology trainees' surgery skills for orchiopexy.

INTRODUCTION: Established methods to train pediatric urology surgery by residency training programs require updating in response to administrative changes such as new, reduced trainee duty hours. Therefore, new objective methods must be developed to teach trainees. We approached this need by creating e-learning to teach attendings objective assessment of trainee skills using the Zwisch scale, an established assessment tool. The aim of this study was to identify whether or not e-learning is an appropriate platform for effective teaching of this assessment tool, by assessing inter-rater correlation of assessments made by the attendings after participation in the e-learning. Pediatric orchiopexy was used as the index case. METHODS: An e-learning tool was created to teach attending surgeons objective assessment of trainees' surgical skills. First, e-learning content was created which showed the assessment method videotape of resident surgery done in the operating room. Next, attendings were enrolled to e-learn this method. Finally, the ability of enrollees to assess resident surgery skill performance was tested. Namely, test video was made showing a trainee performing inguinal orchiopexy. All enrollees viewed the same online videos. Assessments of surgical skills (Zwisch scale) were entered into an online survey. Data were analyzed by intercorrelation coefficient kappa analysis (strong correlation was ICC ≥ 0.7). RESULTS: A total of 11 attendings were enrolled. All accessed the online learning and then made assessments of surgical skills trainees showed on videotapes. The e-learning comprised three modules: 1. "Core concepts," in which users learned the assessment tool methods; 2. "Learn to assess," in which users learned how to assess by watching video clips, explaining the assessment method; and 3. "Test," in which users tested their skill at making assessments by watching video clips and then actively inputting their ratings of surgical and global skills as viewed in the video clips (Figure). A total of 89 surgical skill ratings were performed with 56 (65%) exact matches between raters and 89 (100%) matched within one rank. Interclass correlation coefficient (ANOVA) showed statistically significant correlation. (r = 0.725, 95% CI 0.571-0.837, F = 3.976, p ≤ 0.00001). Kappa analysis of inter-rater reliability showed strong consensus between attendings for average measures with ICC = 0.71, 95% CI 0.46-0.95 (p = 0.03). CONCLUSION: We launched e-learning to teach pediatric urology attendings "how to" assess trainee surgical skills objectively (Zwisch scale). After e-learning, there was strong inter-rater correlation in assessments made. We plan to extend such e-learning to pediatric urology surgical training programs.